Annals for Hospitalists Inpatient Notes - COVID-19, Hospital Medicine, and a Way Forward
Authors: Marisha Burden, Vineet Chopra
Journal: Annals of Internal Medicine (2022)

Web ExclusivesMay 2022Annals for Hospitalists Inpatient Notes - COVID-19, Hospital Medicine, and a Way ForwardFREEMarisha Burden, MD and Vineet Chopra, MD, MScMarisha Burden, MDDivision of Hospital Medicine, Department Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado (M.B., V.C.).Search for more papers by this author and Vineet Chopra, MD, MScDivision of Hospital Medicine, Department Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado (M.B., V.C.).Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/M22-0993 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Our field—the specialty of hospital medicine—began as a means to solve problems. At the turn of the century, resident duty hour restrictions became stricter. Payment and policy reforms aimed at primary care physicians challenged the status quo of mixed inpatient and outpatient care. In addition, advances in technology, care pathways, and value-based initiatives put pressure on hospital systems to develop structures for safe and efficient care delivery. Hospital-based medicine emerged to address these challenges and has since become the largest and fastest growing specialty in internal medicine.It should come as little surprise that, in the face of a once-in-a-lifetime pandemic, a field that was born to address challenges is having its moment. With the unfolding of COVID-19 in the United States, the operational, clinical, strategic, and quality improvement skills of the hospitalist profession have been on full display. Armed with agility, a “can-do” attitude, and a generalist skill set, hospitalists like us have cared for countless patients with COVID-19. The delivery of such care has led to a revolution in the field. Many hospitalists now have roles in critical care delivery, implementation of institutional surge plans, and coordination of infection control policies (1, 2). We have become the proverbial tip of the spear, synthesizing emerging data and drafting guidelines and care pathways with a raw “here's how” approach. Our portfolio of care has also expanded beyond the hospital to encompass remote monitoring programs and post-acute clinics.We have gained much from the constant challenge of the pandemic. We have learned that we are resilient. Subspecialists and outpatient clinicians have witnessed the value of the systems and the clinical knowledge that hospitalists provide. We have cemented the role of advanced practice providers in acute care settings. Advanced practice providers have not only stepped into the breach to serve on inpatient teams but have often moved into leadership roles. In addition, we have learned the importance of teamwork, realizing that support from colleagues across many disciplines is what made “surging” possible. Hospitalists across the country also came together to share information, lived experiences, and on-the-fly adaptations (3), building a connected community that will last for years to come.However, these gains have not come without costs. The effort has taken an inestimable toll on the workforce. We have faced moral and ethical challenges, such as compassion fatigue, whether to ration protective equipment, and how to approach the unvaccinated. Our jobs have morphed constantly while our colleagues have fallen ill, and even lost their lives. In a field already prone to burnout, the exact toll of COVID-19 on hospital medicine remains unclear, but worrisome signals have emerged. Qualitative research has highlighted the mental anguish placed on front-line hospitalists who face unrelenting workloads. Clinicians with young families, prototypical of our workforce, have struggled to balance childcare with work, which disproportionately affects women in the field (4). These struggles have brought into even sharper focus the importance of equity in advancement, mentorship, and support (5), which require broad systemic structural and cultural changes. Because most U.S. hospitals rely on hospitalists, the implications of what we do next are not trivial.So where do we go from here? We must look within ourselves to craft a path forward. First, we must redouble our efforts to define what constitutes appropriate staffing, compensation, and support for hospital-based clinicians. It is ironic that, despite 2 decades of the field, we still cannot agree on the right patient-to-clinician ratio, the salary a hospitalist should command, or which resources a system should provide to a program beyond salary. Instead of primarily using financial and productivity ratios to guide staffing strategies, we must begin to pair these with patient and workforce outcomes. To augment this effort, we will need to invest in measurement science to craft optimal models of care. Second, we must eliminate cultural and systemic bias and inequities that occur in our workplaces. Institutions must adopt open call processes for opportunities, transparent salary setting, and a zero-tolerance stance on micro- and macroaggressions. Third, it is imperative that we focus on burnout in hospital medicine. Specifically, we must learn more about the drivers of burnout and effective prevention strategies. Fourth, we should take steps to expand the hospitalist skill set to address domains including critical care, addiction medicine, and palliative care. These components may be embedded within residency training, perhaps within hospitalist training tracks. Fifth, hospitalists must look beyond the walls of the building to inform care before and after hospitalization. Our work does create discontinuity, and we must strive to ensure seamless transitions.Although the hurdles seem endless, we see great opportunities for hospitalists continuing long after the pandemic. Now is the time to invest in that future. In doing so, we stand ready to lead through the pandemic and whatever may come next. Forward we go.References1. Linker AS, Kulkarni SA, Astik GJ, et al; HOMERuN COVID-19 Collaborative Working Group. Bracing for the wave: a multi-institutional survey analysis of inpatient workforce adaptations in the first phase of COVID-19. J Gen Intern Med. 2021;36:3456-3461. [PMID: 34047919] doi:10.1007/s11606-021-06697-6 CrossrefMedlineGoogle Scholar2. Chopra V. When COVID-19 strikes your hospital [Editorial]. Ann Intern Med. 2021;174:1319-1320. [PMID: 34224264] doi:10.7326/M21-2681 LinkGoogle Scholar3. Auerbach A, O’Leary KJ, Greysen SR, et al; HOMERuN COVID-19 Collaborative Group. Hospital ward adaptation during the COVID-19 pandemic: a national survey of academic medical centers. J Hosp Med. 2020;15:483-488. [PMID: 32804610] doi:10.12788/jhm.3476 CrossrefMedlineGoogle Scholar4. Gottenborg E, Yu A, Naderi R, et al. COVID-19's impact on faculty and staff at a school of medicine in the US: what is the blueprint for the future. BMC Health Serv Res. 2021;21:395. [PMID: 33910541] doi:10.1186/s12913-021-06411-6 CrossrefMedlineGoogle Scholar5. Woitowich NC, Jain S, Arora VM, et al. COVID-19 threatens progress toward gender equity within academic medicine. Acad Med. 2021;96:813-816. [PMID: 33003040] doi:10.1097/ACM.0000000000003782 CrossrefMedlineGoogle Scholar Comments0 CommentsSign In to Submit A Comment Author, Article, and Disclosure InformationAffiliations: Division of Hospital Medicine, Department Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado (M.B., V.C.).Note: Dr. Vineet Chopra, Deputy Editor for Annals, had no role in the editorial review of or decision to publish this article.Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M22-0993.Corresponding Author: Marisha Burden, MD, Division of Hospital Medicine, University of Colorado School of Medicine, Leprino Building, 4th Floor, 12401 East 17th Avenue, Mailstop F-782, Aurora, CO 80045; e-mail, marisha.[email protected]edu. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetailsSee AlsoAnnals for Hospitalists - May 2022 Megan Mack , Matthew Luzum , and David H. Wesorick Metrics May 2022Volume 175, Issue 5Page: HO2-HO3KeywordsCOVID-19Hospital medicineHospitalistsQuality improvement ePublished: 17 May 2022 Issue Published: May 2022 Copyright & PermissionsCopyright © 2022 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...